Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
How do you approach therapy for severe osteoporosis after an initial 12 months of romosozumab?
After 12 months of romosozumab, most likely the patient will still need additional therapy. If you can get a bone mineral density, that can guide you into what the best next medication can be. If the patient still has significant osteoporosis or fracture during the treatment with romosozumab, I woul...
How would you manage a patient SLE who is planning pregnancy and has serologically active disease (elevated dsDNA, low C3/C4), mild arthritis, and is otherwise asymptomatic on hydroxychloroquine 200 mg BID and methotrexate 15 mg weekly?
Options I'd consider would be sulfasalazine and/or azathioprine, as mentioned. I think the question is will SSZ+HCQ be enough for her SLE or will AZA+HCQ be enough for her arthritis? Could certainly add Belimumab to her HCQ, although it has a much longer onset of action and certainly less pregnancy ...
When do you recommend initiation of targeted therapies in active RA with history of malignancy?
In patient with RA and a history of malignancy, I generally recommend the same therapy that I would recommend in the absence of a malignancy history. This is consistent with the most recent ACR guidelines for the management of RA (Fraenkel et al., PMID 34101387). Consistent with FDA labeling, I'd ge...
How would you approach the treatment of erosive inflammatory arthritis (RA or SpA) in a patient with multiple sclerosis on ocrelizumab who has failed csDMARD therapy?
This is a challenging situation to confront, however, as more non- rheumatological illnesses are being managed with biologics, we will be facing this issue with greater frequency. Regarding multiple sclerosis (MS), one should be aware that the major metabolite of leflunomide, teriflunomide, is a bra...
Would you choose bimekizumab over other IL-17 inhibitors in patients with increased levels of disease related pain and poor functional status?
In the absence of head-to-head trials, I hesitate to make a recommendation regarding which IL 17 inhibitor is better in this situation. It is also very unlikely that the makers of the three IL 17 inhibitors would conduct such trials. Network meta analysis and matching-adjusted indirect comparison ar...
How do you approach the initial treatment for a patient presenting with MAS/HLH as the initial manifestation of SLE?
For rare manifestions of systemic lupus erythematosus (SLE) such as macrophage activation syndrome/hemophagocytic lymphohistiocytosis (MAS/HLH), I like to refer to the recent paper by the Members of the European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, th...
How would you approach escalation of therapy in an adult patient with refractory Still’s disease and associated MAS/HLH (ferritin >100,000, transaminitis, DIC) despite high-dose steroids, high-dose anakinra, tocilizumab, and ruxolitinib?
Emapalumab is an appropriate escalation in the described circumstance. I have no experience, and there is little published data as of yet with MAS825, but I would position this as an option to pursue before using etoposide. While there may be an indication of confounding, etoposide use nonetheless h...
How do you counsel a patient with SLE who has labs suggesting active non-renal disease on the benefits of escalation of treatment if they aren't experiencing noticeable symptoms?
Non-renal disease is predominantly in the skin and joints. These are assessed by physical examination (not by laboratory tests). Yes, there are some patients with mild synovitis by exam who are NOT bothered by it, but most patients will have morning stiffness and require treatment. Patients who are ...
What do you feel are the potential barriers to widespread use of obinutuzumab in proliferative lupus nephritis?
1. Insurance Coverage: Oh, easy one! Since it is not FDA-approved yet for lupus nephritis (I bet it will be though... great data so far), insurance will unlikely cover it, except for a few (like Tricare, which is sometimes easier to get off-label drugs). I am fortunate to have the NIH Lupus Center c...
Have you seen synovitis (even if subtle) with aromatase inhibitor musculoskeletal syndrome?
Aromatase inhibitor (AI) drugs have been associated with the onset of arthralgias and myalgias. These have been reported to occur in as many as half the women prescribed this class of drug. The onset of an inflammatory arthritis is far less common. There are selected case reports documenting the ons...